New Patient Registration

Brantford Central Dental

Personal Information
Valid first name is required.
Valid last name is required.
Please select/type a valid date.
Please select gender.
Please enter your address.
Please provide a valid city name.
Please provide a valid province.
A valid zip code is required.
Please provide a valid phone number.
Please provide a valid email address.
1. Do you have dental insurance?*
Medical History
Your answers are for our records only and will be confidential.
1. Are you being treated for any medical condition or have you been treated or hospitalized for any illnesses or operations?*
2. When was you last medical check-up?
3. Are you take any medication?*
4. Do you have any allergies?*
5. Have you ever had a peculiar or adverse reaction to any medicines or injections?*
6. Do you have any family history of diseases or medical problems?*
7. Do you have any conditions or therapies that could affect your immune system?*
When is the expected due date?
Dental History
1. Have you had any allergic reaction to "freezing", difficult extractions or prolonged bleeding after extraction in the past?*
2. Have you had dental radiographs (X-ray)? If yes, When
3. When did you have your last dental visit or hygiene care (dental cleanings)?
Informed Consent/General Release
* I, the undersigned, state that I have provided an accurate and complete Medical/Dental history and have not knowingly omitted any information. I consent to my physician being contacted if neccessary. I agree, in accordance with the rules of the Privacy Act, your office may collect, use and disclose my personal information as required, I autrhorize the dentist to perform diagnostic, dental and oral surgery procedures and services including the use of anaesthetic as may be neccessary, I also understand that I assume resposibility for any and all fees associated width these procedures and services provided to me or my dependants.
Please sign here:*